General Biopsychosocial model paper from 2004

edit: I've just realised that I forgot to post a link to the paper I started this thread about! Sorry about that. It's often slightly disappointing to read my old posts and realise how garbled that are!
Here's the link:

I've just read this and the replies (it did take me a day to get through it all), and thought it was kind of interesting. In some ways it sounded really sweet, in other ways, terrifyingly naive about the way the BPS model would actually lead to patients being treated.

Anyone thinking that it was a good idea to promote a biopsychosocial approach to CFS within the NHS must have not cared much about the impact it would have upon patients, or have been utterly deluded about the psychosocial setting most medical staff are operating within.

Some of the things the above paper expects from doctors would require them to be super-human... or else will inevitably lead to quackery.

In the White book on BPS they talk about the model only gaining influence when politicians and civil servants realise it can be used as a way of saving money... and this now seems to be the primary role of BPS: to justify cutbacks in care and assistance for those with health problems. How very proud all those who made their careers out of it must be.

Hi Esther12, I am not sure its this clear cut. Like the ideological divide between right and left wings of politics, I think there is a divide in medical attitudes. I suspect that many of these people do indeed think they are doing the right thing - but because they are ideologically and not factually driven they are dangerously unaware of the consequences. Some are aware though - I cannot see an alternative to that conclusion - but to them its political. They want their agenda, and if a few have to be sacrificed along the way, too bad. This is bad politics, its bad science, its bad medicine. Whenever ideology over-rides facts there is a problem.

I think the idea of BPS is fine. I think the implementation of that idea, current practice, is dangerously flawed. The driving force seems to be fear. Medical and political thinking based on fear (and its cousin hatred) underlies many of the worst periods in history.

How is this about fear? In politics its about fear of the rising social costs. Add rising resource costs that are expected and the economies of these countries are going to be heavily burdoned. In the case of the psychiatrists its fear that those who practice psychosomatic medicine are a dying breed. They are losing relevance. This is their attempt at a comeback. They are failing, and one day this will be seen for what it is.

In the White book on BPS they talk about the model only gaining influence when politicians and civil servants realise it can be used as a way of saving money... and this now seems to be the primary role of BPS: to justify cutbacks in care and assistance for those with health problems. How very proud all those who made their careers out of it must be.

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That's very interesting. Do you have any useable quotes from that source?

I can't copy and paste! I didn't re-read it all, but it looks like it says pretty much what I remembered. They also mention the importance of systematic reviews, and as we know, they can easily be skewed one way or the other. This could explain why so many seemingly pointless ones get pumped out.

Hi Esther12, I am not sure its this clear cut. Like the ideological divide between right and left wings of politics, I think there is a divide in medical attitudes. I suspect that many of these people do indeed think they are doing the right thing - but because they are ideologically and not factually driven they are dangerously unaware of the consequences.

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I didn't mean to say it was clear cut, and agree that many of the proponents of BPS probably thought that they were doing a good thing which would help patients. I just think that lots of people doing bad things are motivated by a desire to do good.

I think the idea of BPS is fine. I think the implementation of that idea, current practice, is dangerously flawed. The driving force seems to be fear. Medical and political thinking based on fear (and its cousin hatred) underlies many of the worst periods in history.

How is this about fear? In politics its about fear of the rising social costs. Add rising resource costs that are expected and the economies of these countries are going to be heavily burdoned. In the case of the psychiatrists its fear that those who practice psychosomatic medicine are a dying breed. They are losing relevance. This is their attempt at a comeback. They are failing, and one day this will be seen for what it is.

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I see what you're saying, but when the idea itself is so tied up to pragmatism and claims about results, I think that it's hard to say it's a good idea implemented poorly. I also do not see any way that it could be implemented well within our current social structures, or without some dramatic improvement in our ability to train and regulate our medical staff. A BPS approach seems doomed to fail, and doomed to continue to fail for the foreseeable future.

I know what you mean about some of the things said as part of the BPS approach to disability sounding good in an abstract kind-of way, but one can say that communism is a good idea in principle, or some other benevolent form of authoritarianism... but they're only good ideas if we assume that people in positions of power and authority are less self-interested, prejudiced and stupid than they really are. In reality, they're bad ideas... and that's where ideas should be judged imo.

Edit: I wasn't able to get it all, but this is part of the section from Peter White's BPS book OB asked about:

from page 218 of Biopsychosocial Medicine: An Integrated Approach to Understanding Illness, edited by Peter White.

Wessely: Mansel Aylward, you are involved with policy definitions. What have you heard here that might influence your secretary of state?

Aylward: I have been given a lot of information that reinforces some of the messages that I have passed on to decision makers. I haven't heard anything startlingly new, but I am happy to have my views confirmed. We have made some significant progress. We had some great difficulty last year persuading certain people that the way forward in the more effective assessment of disability and its management in people on state benefits lay more with a BPS approach to rehabilitation, job retention and recovery, than a focus on economic disincentives or wielding the stick approach. There seems to be an antipathy in some part of Government towards anything that is perceived as fuzzy or nebulous, without a hard evidence base. If the BPS approach is perceived in this way and is competing for investment with hard policies focusing on bed occupancy and delivery of acute services, it is very difficult to get the Department of Health, among others in Government, to favour health-focused interventions and rehabilitation adopting the BPS approach. But in recent month I'm beginning to see a change. The Department for Work and Pensions may now have been persuaded to invest in initiating pilot studies in various areas of the country, in particular involving benefit recipients with back pain and fatigue, to see if all the talk about the BPS approach has any basis in improving outcomes.

Wessely: What made some of the policy makers change their views?

Aylward: Systematic reviews of the literature garnering evidence to support the BPS concept. Identifications of best practices in using BPS approaches that improve function and rates of return to work, particularly in people with disability caused by back pain. Recent meeting in the form of focus groups of key oppinions makers support with authorative and expert opinion the value of BPS approaches. There are going to be some developments soon.

Wessely: What kind of evidence caused change?

Aylward: The evidence which has been there all along. The key aspect has been effectively communicating the evidence in a far more robust and authoritative way. We also ran a series of workshops where we discussed and evaluated various approaches to facilitate return to work and to address the rising numbers of people in receipt of incapacity benefits. Some £25 billion per year is being spent on state benefits resting either directly or indirectly on a medical basis. The prospect of effective interventions that might reduce that expenditure are powerful catalysts for change.

Waddell: To take this a stage further, I am not sure that evidence is what convinces people. We do need an evidence base, but it is ideas that really influence people. People go to war for ideas, not for evidence. When you look at changing practice, it is really about ideas rather than evidence. My hesitation about what was said earlier is that everything seem to show the the behaviour of health professionals is difficult to change. But there are some suggestions from the Australian education campaign, Kate Lorig's work, and our work in Scotland, that it may actually be easier to change patients and the public and they will then force the professionals to change. The information from Australia has helped tremendously [1,2]. Some decision makers were very jaundiced, but this has played a role in convincing them that there is something in that and that it will save money. It's all about money. The main thing was to persuade the treasury that there was an opportunity for keeping costs down, particularly over the longer term.

Drossman: One of the efforts in the USA that has had some influence on Congress is the burden of illness study carried out be the American Gastroenterology Assocations. They identified the costs in terms of direct and indirect costs. Direct costs refer to the costs related to the healthcare, such as medication and physician visits and indirect costs are other way in which the illness impacts on the economy, for example, loss of work productivity or wages due to illness. Using irritable bowel syndrome (IBS) as an example the prevalence is 15 million in the USA. When you multiply this by the number of dollars spent in terms of physician visits and prescriptions, it exceeds the cost burden of inflammatory bowel disease (IBD). Thus the higher prevalence (about 100 times great) for IBS offsets the high cost per patient of IBD, yielding greater cost to society. The cost to the economy is about US$2 billion of direct and US$20 billion of indirect costs. This had some inflence on Congress. It is not proving that you can treat it that matters but proving that the economic burden is there and that effort must be placed on finding better treatments.

Wessely: I once tried to add up the cost burden of a range of conditions and it comes to more than the gross national product of the entire western world!

Lorig: Particularly for morbidity.

Lewin: One of the other things that Greville Mitchell is helping us do through One Health is an analysis that will look at the lost opportunity costs from not using cognitive behavioural therapy (CBT) approaches. We are doing this in collaboration with Jos Kleijnen. This is a complicated procedure because we haven't even got an agreed definition of CBT. We'd be delighted to have any suggestions for how we might do this.

Wessely: Can I clarify? Is Jos also doing a review of more direct psychosocial interventions in this area?

Lewin: Yes. The study is looking at the possible costs savings. What would the Government gain if they were to spend more on these areas?

Mitchell: People are pretty limited in viewing government future budgets. They will escalate: That is a fact of life. Therefore, if you are going to add to this bill you won't catch the government's attention, even if you

Hi Esther12, I agree that the BPS approach is being used by some political factions to drive social agendas that would otherwise be considered abhorent. They can point to the medical papers and say, hey, we are doing the right thing. The current fight in the UK against ATOS and the government implementation of austerity measures by removing benefits from disabled people, as easy targets, is a case in point.

There is failure on so many levels. We, as patients, have failed to see what is happening for far too long - we were dead certain something was wrong, but never clear as to what it was - and to some extent we are still floundering. The general public not only failed to see it but failed (and is still failing) to address the problem. The public is informed by the media who are supposed to be our watchdogs - the media have failed even worse than the public or patients. There is some sign that more and more are aware of this however. The politicians have failed because they are supposed to address issues that are not addressed by other mechanisms. There is too much buck passing and no leadership on these issues.

In the medical corner the psychosomatic researchers have failed because they have pursued extremely inadequate research methodologies, and set up precedent for pushing science by political and not rational means. The general medical and scientific communities have failed because they have not called them on it. The institutions have failed as they have permitted unethical practices for generations - something can't be unethical if its widely accepted, can it? I mean its traditional, so it can't be bad, right?

There is plenty of blame to go around. Its systemic. Its less about individual blame than about how badly the whole system is set up. There are no checks and balances in the system that are working.

Extreme right wing politics tends to drive itself. Right wing politics is an essential part of the democratic process. Taken to an extreme we can wind up with a police state - extreme left wing politics is equally problematic. More often however, historically, there is a sudden and dramatic correction in direction as people become aware. It just requires a sufficient number of people to stand up and say, stop, enough. That requires communication. At least today we have the internet.

@ alex: I think we're saying pretty similar things, but mybe in slightly different ways.

re blame: I think that checks and balances require the potential for blame, and I don't think systematic problems absolve indviduals of personal blame. Our systems were set up by individuals, and individual researchers had a responsibility to be aware of the systems which they were operating within.

I'm possibly less optimistic about our systems potential to self-correct. As you said, I think that those of us who have been badly affected are still groping towards a firm understanding of exactly what has happened and why... and most people are not that interested in doing the work needed to understand these issues. It's really boring! I'm concerned that societies growing ability to pump out complicated and misleading research is going to lead to ever less genuine democratic participation, and much more potential for elites to be able to manipulate and control the social consensus - at least when it comes to matters which affect only a minority, and naturally tend attract little public attention and interest. Or it could be that people will decide that it's important to make a change, and impose more accountability upon those in power and authority. Fingers crossed.

Some people might be interested in Waddell and Aylaward's Models of Disability pamphlet.

Sorry for not pulling out quotes and summaries for what I've been reading... I keep forgetting to do that, and some documents don't let me when I try. I've only read the first 20 pages of this, and am feeling wiped out today, so will not be getting any further.

This is the way those with health problems are now seen: 'unproductive'. There's no real concern about the diminished opportunities and capacity that many face, or willingness to promote their personal autonomy or freedom, just a desire to make them less of a burden to those with power and authority. And they know we're too weak to fight back.

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This sort of thing is particularly problematic in the case of CFS, where attempts to 'improve' the way patients feel about their condition has included encouraging them to believe that recovery was under personal control, or that the patient's loss of capacity was a result of depression, or deconditioning, or a fear of activity... regardless of the likely accuracy of these claims. The notion that people with poorly understood health problems deserve to be manipulated and managed in this way is repulsive.

There's a later section on personal responsibility and self-interest, and I really wonder if the authors thought about how it might apply to themselves, and what responsibility they hold for the suffering which has been inflicted upon others as a result of their work.

Oops - just found a way to copy text. I using a funny setting before, instead of the PDF.

Free will and personal responsibility

Some personal characteristics and psychological processes are deeply ingrained or
beyond the control of the individual, but conscious choice, motivation and effort still
play a central role in sickness and disability (Leonard et al 1999, Halligan et al 2003,
Aylward 2003).

Human beings are driven by both self-interest and altruism,19 but self-interest is
generally dominant. There is nothing morally wrong with self-interest, and it should
not be misinterpreted as selfishness or greed. Whatever the philosophical debate about
the extent of free will, the law takes a pragmatic approach to ‘intent’ (Gordon 2000) –
acting intentionally, actions with a particular intent or purpose. Individual liberty, free
will and personal responsibility for one’s actions are taken to be the norm unless there
is strong evidence to the contrary. People act consciously, aware of what they are doing
and of the likely consequences (i.e. not accidentally or in ignorance).

Sick and disabled people may face considerable constraints on their behaviour. In
practice, choice may be constrained by biological or psychological limitations, by genuine
(even if mistaken) perceptions and beliefs, and by social or occupational factors beyond
the control of the individual, lack of autonomy and self-esteem. Sick and disabled
people face considerable social barriers and disadvantages. But, for all the qualifications,
most sick and disabled people bear personal responsibility for their actions. Very few
have a severe mental illness or disorder that absolves them from responsibility. For most
people with common health problems, decisions about being (un)fit for work, taking
sickness absence or claiming benefits are conscious and rational decisions, free choices
with full awareness and intent, for which they must take responsibility. Accepting that
they have a genuine health problem, most claimants are nevertheless answerable to
‘whether it would be unreasonable to expect [me] to seek or be available for work’. The
principle of ‘reasonableness’ is sufficiently broad to allow for the nature and severity of
the health condition and for social circumstances. The corollary is that any judgements
must be made with understanding and compassion.

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I think it's fair to assume that Aylward and UNUM are self-interested, and should be assumed to be aware of what they are doing and their action's likely consequences.

Aylward criticises the old sick role, and comes up with a new one:

The original description of the sick role (Parsons
1951)48 applied best to acute physical illness:
Rights:
The patient is absolved from responsibility for • illness (i.e. they are the subject of
injury or disease beyond their control).
• They are exempt from normal social role responsibilities.
• They are entitled to special attention and support.
This is conditional upon:
• The patient accepting that to be sick is undesirable, and that it would be a good thing
to get well as expeditiously as possible.
• The patient accepting an obligation to seek healthcare and to cooperate in the
process of getting well.

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Box 14
The sick role with common health problems
Rights
Absolved from responsibility for the health condition (i.e. no fault or discrimination)
Access to healthcare for help to relieve/control symptoms
Modify normal social duties and responsibilities to a degree appropriate to the nature
and severity of the illness (which leads to issues of assessment and legitimization)
Entitlement to (temporary) sickness absence and income support (if justified).
Obligations
Share responsibility for management of the health condition and rehabilitation
Recognize that symptoms and feeling unwell do not necessarily mean incapacity for
work
Recognize that the sick role is temporary, in the expectation of recovery
Be motivated and cooperate with rehabilitation
Return to work when reasonably possible (even if there are still some symptoms).

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All of these aspects make it difficult to reject the medical model. In contrast, the biopsychosocial
model presents human illness as the outcome of a complex set of biological,
psychological and social factors and interactions, which can be difficult to define and
control. Clinical practice must live with uncertainty and focus on the most important,
manageable issues. A biopsychosocial approach places greater demands on health professionals,
for which many feel untrained and uncomfortable.

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Luckily for the health professional, there are no new systems of accountability or regulation, so if the are unable to live up to these additional demands, and harm their patients, they won't bear any of the cost of that. Placing patients under the power of people unable to live up to the demands of the model they're instructed to follow is win-win, so long as you're not over-cautious about 'do no harm'.

The major limitation of the biopsychosocial approach has been the lack of simple
clinical tools to assess psychosocial issues and simple, practical interventions to address
them (Kendall et al 1997, Borkan et al 2002, Kendall & Burton 2009). After more than
30 years, and despite agreement on the importance of psychosocial factors, there is
relatively little empirical evidence for effective biopsychosocial interventions at an individual
level. The challenge is to develop simple, practical, biopsychosocial messages for
routine practice, and the evidence base for their effectiveness.28

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One would have thought that this might give pause to thought? We've now had the two largest RCTs of biopsyhcosocial interventions - FINE showing no benefit, and leading medical staff to view patients as "bastards [who] don't want to get better", and PACE which showed some minor improvements in subjective questionnaire scores (following necessarily unblinded treatment), but which White has reported led to no improvement in employment levels (although he's not quite ready to publish that data).

The starting point is that recovery is
generally to be expected, even if with some persisting or recurrent symptoms.

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What a cheering starting point.

Based on the biopsychosocial model and
previous experience of back pain, possible principles might include the following:
• Distinguish mental illness (anxiety, depression, etc.) from personal problems (e.g.
unhappiness and fatigue) and work problems (e.g. pressure and dissatisfaction)

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I think this is the only mention of fatigue - don't worry people... it's a personal problem.

Rights and responsibilities
Welfare is based upon an implicit social contract, and there is also strong public support
for the need to balance rights and responsibilities (White 2000, Einerhand &
Nekkers 2004). Although commonly applied to other areas such as unemployment,
this principle is equally relevant to sickness and disability. ‘Full and equal citizenship
requires disabled individuals ultimately to carry the same responsibilities (and rights) as
others … accepting that these rights and responsibilities may need to be modified to suit
their circumstances and balanced by support to enable them to be met’ (Howard 2004).
The sick role embodies society’s attempt to control sickness, and to support and
encourage return to ‘well’ behaviour. The original description of the sick role (Parsons
1951)48 applied best to acute physical illness:
Rights:
The patient is absolved from responsibility for • illness (i.e. they are the subject of
injury or disease beyond their control).
• They are exempt from normal social role responsibilities.
• They are entitled to special attention and support.
This is conditional upon:
• The patient accepting that to be sick is undesirable, and that it would be a good thing
to get well as expeditiously as possible.
• The patient accepting an obligation to seek healthcare and to cooperate in the
process of getting well.
That analysis was firmly rooted in a medical model, focused on healthcare as the main
exit route from the sick role (Figure 4), and placed responsibility in the hands of health
professionals (Mead & Bower 2000). Crucially, it was often taken to justify sickness
absence until cure was achieved. However, this approach is inappropriate and can be
positively harmful for many common health problems, many of which are persistent or
recurrent and do not have a medical ‘cure’, and where patients must share responsibility
for continued management. The traditional sick role can then become a trap, in which
patients remain passively in the sick role awaiting ‘cure’, even when there is no biological
reason for permanent incapacity. The sick role then needs to be modified for common
health problems (Box 14).
This leads to the principle of ‘conditionality’ (Deacon 1994): entitlement to certain,
publicly provided, welfare benefits should be dependent on the recipient meeting certain
social responsibilities or patterns of behaviour. In summary, the argument runs as
follows:
• Many benefit recipients with less severe health conditions do not have any absolute
physical or mental barrier to work. Personal and psychological factors are central to
incapacity associated with common health problems. The individual has personal
responsibility for his or her actions.
• The sick role involves a balance between social rights and individual responsibilities.
Sickness and disability benefits are given on condition that the recipient meets
these responsibilities. The central obligation is to cooperate with healthcare and
rehabilitation and to (return to) work when reasonably able to, even if with some
persistent or recurrent symptoms.
Most important, however, there • must be safeguards to make sure that any
conditions and obligations do not further disadvantage those individuals who are
already the most disadvantaged (Howard 2004).
• Fairness demands that rights and responsibilities work both ways. The onus ison society to provide the necessary opportunities and support before imposingobligations on sick and disabled people. Employers also have responsibilities.
There is a logical and moral argument for conditionality. There is limited evidence
on its effectiveness (Waddell & Aylward 2005), although it may have more subtle and
indirect effects on changing attitudes and behaviours. So the question is how to use
conditionality and sanctions sensitively to deliver the correct messages and influence
behaviour to the desired ends (Halpern et al 2004).
There is an important caveat. Discussion of rights and responsibilities and conditionality
may be most effective for those closest to the labour market, but it must be
acknowledged that some benefit recipients are ‘hard to help’. This approach may fail the
most disadvantaged and marginalized members of society. Society – and the benefits
system – must make due allowance and provide additional help for ‘the deprived, the
disadvantaged and the excluded’ (Hadler 1996).

Box 14
The sick role with common health problems
Rights
Absolved from responsibility for the health condition (i.e. no fault or discrimination)
Access to healthcare for help to relieve/control symptoms
Modify normal social duties and responsibilities to a degree appropriate to the nature
and severity of the illness (which leads to issues of assessment and legitimization)
Entitlement to (temporary) sickness absence and income support (if justified).
Obligations
Share responsibility for management of the health condition and rehabilitation
Recognize that symptoms and feeling unwell do not necessarily mean incapacity for
work
Recognize that the sick role is temporary, in the expectation of recovery
Be motivated and cooperate with rehabilitation
Return to work when reasonably possible (even if there are still some symptoms).

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Does anyone think that society lived up to that responsibility prior to instituting these reforms?

At the time of writing, the UK is entering a major economic recession, which may
change everything. This should not be an excuse to delay addressing sickness and disability,
but an additional reason to invest now.

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Invest in cutbacks now?!

Is Aylward furiously campaigning against the reforms which have currently being implemented, and are just leading
to widespread poverty amongst those with serious and chronic health problems? If not, one might have to conclude that he is just in the pocket of groups like UNUM, and that his talk of societies responsibilities to the disabled is just cover for the cutbacks which he has helped push through.

Also, I've just realised that I forgot to post a link to the paper I started this thread about! Sorry about that. It's often slightly disappointing to read my old posts and realise how garbled that are!

And finally... I think that there's a nice progression from the ideal of that paper, to the Aylward examination of the biopsychosocial model of disability, to the application of this model by ATOS. Power corrupts pragmatism, and those who do not realise this are useful tools of the powerful. I expect that the problems of the BPS approach to disability would have been less obvious to me if I had not experienced them myself.

Just stumbled upon something where Lord Freud is using the Aylward leaflet from above to justify reforms to DLA (excuses to cut spending on helping those with health problems).

I sent round a rather interesting piece of analysis to many noble Lords in the Committee, called Models of Sickness and Disability, which showed the differences between the models, explaining the medical model, the reaction of the social model against the pure medical model and the synthesis of the biopsychosocial model. The summary of the biopsychosocial model in the analysis is that:
"Sickness and disability are best overcome by an appropriate combination of healthcare, rehabilitation, personal effort and social/work adjustments".
There is a coherent theory behind this assessment.

There's loads of funny stuff about Lord Freud about. Apparently he's as clueless as he sounds, and admitted to knowing nothing about welfare issues three weeks before he released a report recommending a series of dramatic reforms. It seems that he's just happy to do what those with power want him to, and screw over the sick and disabled.